Organised By
Organised By
Department of Dietetic and Food Service, Hospital Serdang
Corresponding author’s email: noriati_ujang@moh.gov.my
ABSTRACT
BACKGROUND AND AIM
The purpose of Nutritional Diagnosis (ND) is to identify and label specific nutrition problems that dietitians are responsible for treating. This follow-up audit aimed to determine whether there will be an increase in the percentage of written nutrition diagnosis in the case notes as compared to the previous audit, identify the different domains used as well as to identify the barriers towards writing nutrition diagnosis in dietetic case notes.
METHODS AND MATERIALS
We retrospectively reviewed 170 dietetic case notes written from February till May 2016. Systematic Random Sampling was used to select new inpatient case notes from the electronic medical records. A proforma and structured questionnaire were used for data collection. Data analysis was done using SPSS ver. 20.
RESULTS
We found that 97.6% of the case notes had nutrition diagnosis written in it (increased by 7.5%), and 88.2% followed the standardized terminology. The most commonly used domain was intake (74.7%), followed by behavioral – environmental (12.9%) and clinical (6.5%). Forgetfulness of the dietitian and inability to make nutrition diagnosis due to patient’s refusal for dietary consultation were the main reasons why nutrition diagnosis was not written in the case notes.
CONCLUSION
Majority of dietetic case notes in our hospital has nutrition diagnosis written and followed the standardized terminology.
No of words – 241 without keywords
Keywords: nutrition diagnosis, dietetic case notes